Healthcare Provider Details

I. General information

NPI: 1982152237
Provider Name (Legal Business Name): EMBODIED SOUL CHIROPRACTIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2016
Last Update Date: 09/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5305 HERITAGE CT NE
ALBUQUERQUE NM
87109-3178
US

IV. Provider business mailing address

5305 HERITAGE CT NE
ALBUQUERQUE NM
87109-3178
US

V. Phone/Fax

Practice location:
  • Phone: 505-822-5001
  • Fax:
Mailing address:
  • Phone: 505-822-5001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2146
License Number StateNM

VIII. Authorized Official

Name: DR. RANDALL ADAM POLGAR
Title or Position: DOCTOR OF CHIROPRACTIC
Credential: D.C.
Phone: 408-373-1358